Acute Hospital Activity and NHS Beds Information for Scotland

Annual – Year ending 31 March 2020

A National Statistics release for Scotland Public Health Scotland

This is a National Statistics publication

National Statistics status means that the official statistics meet the highest standards of trustworthiness, quality and public value. They are identified by the quality mark shown above. The UK Statistics Authority has designated these statistics as National Statistics signifying compliance with the Code of Practice for Statistics. Once statistics have been designated as National Statistics, it is a statutory requirement that the Code of Practice shall continue to be observed. The statistics last underwent a full assessment by the Office for Statistics Regulation (OSR) against the Code of Practice in September 2011. The OSR is the regulatory arm of the UK Statistics Authority.

Find out more about the Code of Practice at: https://www.statisticsauthority.gov.uk/osr/code-of-practice/

Find out more about National Statistics at: https://www.statisticsauthority.gov.uk/national-statistician/types-of-official-statistics/

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Contents

Introduction ...... 3 COVID-19 ...... 3 Background ...... 4 Future Developments ...... 4 Main Points ...... 6 Results and Commentary ...... 8 Section A: The use of outpatient services ...... 8 Did Not Attends’ at outpatient clinics ...... 10 Section B: Accident and Emergency ...... 12 Section C: Acute hospital admissions ...... 14 Multiple admissions to hospital...... 16 Episodes of Care and Continuous Inpatient Stays ...... 16 How long do people stay in hospital? ...... 17 Beds ...... 20 Reasons for admission ...... 21 What procedures are carried out? ...... 23 Where are patients treated? ...... 24 Section D: Psychiatric Hospital Activity...... 26 Section E: Now and then – a brief look over the past two decades...... 28 Glossary ...... 30 Contact ...... 35 Further Information ...... 35 Open data ...... 35 Rate this publication ...... 36 Appendices ...... 37 Appendix 1 – Background information ...... 37 Appendix 2 – Data Quality and Completeness ...... 38 Appendix 3 – Publication Metadata...... 40 Appendix 4 – Early access details ...... 47 Appendix 5 – PHS and Official Statistics ...... 48

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Introduction The NHS in Scotland delivers a wide range of specialist care and treatment to the people of Scotland. Services provided in NHS hospitals are diverse ranging across specialist diagnostic procedures to complex and life-saving surgery to meet both planned and emergency needs. This publication provides a general overview of the use of hospital services for the financial year ending 2019/20 using routinely collected data. This overview is primarily based on the range of acute medical and surgical hospital services that are provided in Scotland and covers most of the inpatient, daycase and outpatient services used by patients. Additionally, there are sections on Accident & Emergency and Psychiatric activity. The overall expenditure associated with acute services is around £4.9bn, which represents around 41% of total NHS spend1. Admissions into maternity wards are not part of this report. As well as reporting on activity within 2019/20, some trend information highlighting changes in service provision over the past twenty years is also presented. Note that individual figures referred to throughout this report may not add up to totals, due to rounding. As well as this narrative, detailed information is given in a set of data tables which accompany this report and can be accessed here. These tables include statistical information on specialties, medical diagnoses, the number and type of procedures carried out, admission type i.e. elective/emergency admissions, length of stay, and bed statistics for NHSScotland. Information is available at NHS Board level, council and hospital level, as well as age, gender and the Scottish Index of Multiple Deprivation (SIMD) for selected data tables.

COVID-19 On 1 March 2020, the first person in Scotland tested positive for COVID-19. On the 17 March NHS Scotland was placed on an emergency footing by the Cabinet Secretary. Since the start of the outbreak, Public Health Scotland (PHS) has been working closely with the Scottish Government and health and care colleagues to support the surveillance and monitoring of COVID-19 amongst the population. There is a large amount of data being regularly published regarding COVID-19 (for example, PHS weekly reports, including wider impacts analysis; Coronavirus in Scotland – Scottish Government and Deaths involving coronavirus in Scotland – National Records of Scotland). Please note this release includes the first month of Scotland going into emergency measures due to COVID-19. During this pandemic, NHS Boards, hospitals, and healthcare providers have been required to change their normal way of working to allow them to focus their efforts locally on their COVID-19 response. As such, this will have a direct impact on the volume of hospital activity and trends observed, for example reductions in elective admissions. In addition, some hospitals, and NHS Boards may also see more activity than others.

1 http://www.isdscotland.org/Health-Topics/Finance/Costs/ The overall expenditure figure of £4.9bn refers to 2018/19 acute expenditure from the Cost Book (R310). The total NHS spend figure (41%) refers to 2018/19 expenditure from the Cost Book (R300) published in November 2019.

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Background There are two broad ways in which patients access and make use of acute hospital services. The first is part of a planned or elective pathway of care which is normally initiated following a visit to the GP or other healthcare professional, and may result in a referral to see a consultant as an outpatient for specialist advice or diagnosis. This outpatient appointment may then result in an onward referral for further tests or admission into hospital for treatment. The second way in which patients make use of hospital services is as a result of an emergency referral either by a healthcare professional or directly by the patient themself. This may be via an Accident & Emergency department, directly to Ambulatory Emergency Care or to an Acute Assessment Unit, where it will be decided if the patient needs to be admitted to an inpatient ward; different models of emergency care are evolving to meet the challenge of increased complex cases and improved outcomes for patients. Further information on emergency admissions and unscheduled care can be found within this report, and within the Emergency Department Activity pages on the website. Within this report, the overview of outpatient activity and services is presented first, followed by information on attendances at Accident and Emergency departments. Next, information is presented on the number and type of acute hospital admissions, followed by a summary of psychiatric hospital admissions. The final section presents a snapshot of some of the ways in which hospital care has changed over the past 20 years. Note -This report uses the terminology “admissions” to describe hospital activity in the reported periods. Strictly speaking the activity actually refers to hospital discharges in the reported time period rather than admissions. The difference between admissions and discharges is of small importance at the level of detail shown and in the context of this publication. For the purpose of these analyses, hospital admissions are defined as the number of continuous inpatient stays (CIS) in hospital where the patient was admitted. When showing information by CIS, the admission type e.g. elective/emergency is determined by the first admitting episode. As a result, transfers will generally not appear within the CIS analysis. When a transfer does appear it is often the result of a patient being transferred from another provider unit e.g. outwith Scotland. However, there will also be instances where the admission type has been incorrectly coded, unfortunately it is not possible to fully ascertain what the correct admission type should have been. As a result, you will see that a small proportion of transfers do appear within the various tables. See the Episodes of Care and Continuous Inpatient Stays section for further information.

Future Developments In December 2016 the Scottish Government published “The Modern Outpatient: A Collaborative Approach 2017-2020” that aims to deliver care closer to the patients home, provide more person-centred care, utilise new and emerging technologies, and maximise the role of clinicians across Primary, Secondary and community based services.

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Early in 2018, the Modernising Outpatient Programme (MOP) led by the Scottish Government, commissioned Public Health Scotland (PHS) [previously Public Health & Intelligence (PHI)] to work with stakeholders to review the SMR00 dataset, make an initial assessment of the need for change, and identify key deliverables. PHS Data Advice identified gaps in the existing national dataset (SMR00) that does not allow the full pathway to be appropriately recorded.

In order to meet the objectives, set out in the “Modern Outpatient” agenda and to ensure our secondary care datasets meet future information needs, PHS has been working with key stakeholders to establish a Modernising Patient Pathways Programme (MPPP) of all SMR datasets, with an initial focus on outpatients, to take account of new, and future, service delivery models. This will support patient and service management at Board level as well as providing more accurate and appropriate clinical information at a national level. The SMR00 Modernisation work may have an effect on the number of SMR’s submitted. In addition, other disciplines of staff are increasingly carrying out care for patients which may impact on the number of consultant clinics run.

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Main Points Table 1: Summary of key statistics 2019/20

Around 1.1 million Scottish residents (one in five of the population) visited an outpatient department in 2019/20.

For 2019/20:

- 809,000 (76%) had one new outpatient attendance within the year

- 188,000 (18%) had two new attendances

- 66,000 (6%) had three or more new attendances Outpatient Services Overall there were around 4.2 million total outpatient attendances (new and (excludes maternity and mental return/follow-up) in 2019/20; a 2% decrease on last year (2018/19), with a 7% health clinics) reduction in the last five years (2014/15). The number of new outpatient attendances was over 1.4 million whilst the number of return attendances was around 2.8 million.

DNA rates have been steadily reducing the past few years. 8.2% (127,093) of new outpatient appointments were not kept without prior notification (‘Did Not Attends’), lower than last year (2018/19) and five years ago (2014/15) at 8.4% and 10.2% respectively. In 2019/20, people aged 25-44 were three times more likely not to keep their new outpatient appointment compared to those aged 65 and over (13% vs. 4%).

Around 691,000 Scottish residents (one in eight of the population) were admitted to hospital in 2019/20. Of these, more than two thirds (69%) had a single admission to hospital with three out of ten patients having more than one admission.

Admissions into hospitals For 2019/20:

(excludes admissions to maternity - 474,000 (69%) of those admitted to hospital) had one admission to hospital wards and mental health hospitals) - 124,000 (18%) had two hospital admissions

- 92,000 (13%) had three or more admissions

There were just over 1.2 million admissions to hospital in 2019/20; a 1% decrease compared to last year (2018/19) and a 2% decrease compared to five years ago (2014/15).

For 2019/20:

- 39% were daycases

- 11% were elective inpatient admissions

- 49% were emergency inpatient admissions

In 2019/20 there were just over 1.4 million total procedures performed within the acute hospital care setting. Of these, 83% (~1.2 million) were carried out as a main procedure; a 4% decrease on last year (2018/19), with a 7% decrease in the last four

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years (2015/16). More than seven out of ten (75%) of main procedures were carried out as an outpatient or daycase.

The average length of inpatient stay has been reducing over the years. In 2019/20, the average length of stay was 6.1 days compared to 6.9 days in 2010/11. In 2019/20, the average length of stay for elective inpatients was 3.4 days and 6.7 days for emergency inpatients.

Beds The average number of available hospital beds in Scotland has generally been decreasing over the years. In 2019/20, the average available staffed beds for acute specialties was 13,156; a small 0.5% increase on last year (2018/19) and a 6% decrease when compared to five years ago (2014/15).

For 2019/20:

- 9,260 (70%) were for medical specialties

- 3,896 (30%) were for surgical specialties.

The percentage occupancy has remained relatively stable over the years. In 2019/20, the percentage occupancy for acute specialties was 86.7%.

Data Quality There are known issues with the quality of data presented such as the inpatient and daycase completeness. For more information please see the data issues and completeness document which accompanies this publication.

Source: Outpatient data based on SMR00 & ISD(S)1, Inpatient data comes from SMR01, Beds data based on ISD(S)1.

Trend information on acute activity and beds data can be found in the publication tables accompanying this report.

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Results and Commentary Section A: The use of outpatient services

The majority of interactions with hospital-based services were carried out in an outpatient setting. There were around 4.2 million total outpatient attendances in 2019/20; a 2% decrease on last year (2018/19), with a 7% reduction in the last five years (2014/15). An outpatient appointment will often be the patient’s first contact with hospital services. In 2019/20, nearly 1.1 million people i.e. around one in five of the general population attended a new consultant-led outpatient appointment at least once during the year. The likelihood of attending an outpatient clinic increases significantly with age. Almost one third of the population (31%) aged 65 and over were seen at an outpatient clinic, while around one in six (17%) of those aged 25-44 did so. The chart below shows the percentage of the population attending consultant outpatient services.

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Chart 1: Percentage of the Scottish population who had at least one consultant outpatient attendance in 2019/20 by age group

Source: New Outpatient data are based on SMR00. Population data comes from National Records of Scotland.

The vast majority of people attending usually have only one new outpatient attendance per year, although a small proportion of people do have multiple attendances. In 2019/20, • More than three out of four (76%) of the people (809,000) attending an outpatient clinic had one attendance • 18% (188,000) had two attendances • 6% (66,000) had three or more attendances.

There were around 4.2 million total outpatient attendances in Scotland in 2019/20. Just over 1.4 million were new outpatient attendances and around 2.8 million were return attendances. For each new referral to outpatient there was then, on average, a further two return attendances at the clinic, although the actual number of return appointments for any individual patient will vary depending on the reason for referral and treatment required.

Detailed information on Outpatient attendances can be found in Table 1 - Outpatient Activity (Consultant-led).

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Did Not Attends’ at outpatient clinics People do not always attend their booked outpatient clinic. Whilst some patients will inform the hospital that they cannot attend, 8.2% (127,093) of new outpatient appointments were not kept without prior notification (‘Did Not Attends’) in 2019/20. The likelihood of someone not turning up for their appointment was linked to their age and gender. Males were more likely than females not to keep their appointments (9.2% vs. 7.5%). Patients aged 25–44 were three times more likely not to turn up for their appointment than patients aged 65 and over (13% vs. 4%). Chart 2 shows, for different age groupings, the percentage of new appointments that were not kept.

Chart 2: Level of non-attendance (% Did Not Attends) in 2019/20 by age group

Source: New Outpatient data are based on SMR00. DNAs are based on new attendances only.

There is variation between NHS Boards and specialties in the number of patients who did not attend their appointments. However, DNA rates have been steadily reducing the past few years. This can be attributed to the NHS Boards proactively using Patient Focused Booking (PFB) and attend anywhere; as well as having patients phone to arrange suitable appointments and introducing text reminders. Annual data for year ending March 2020 showed that 8.2% of appointments were missed without prior warning; lower than last year (2018/19) and five years ago (2014/15) at 8.4% and 10.2% respectively.

Detailed information on the level of Did Not Attends can be found in Table 1 - Outpatient Activity (Consultant-led).

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Note – It should be highlighted that previous figures provided may have included an element of estimation for any incomplete or outstanding data submissions. Therefore, subsequent data submissions could be lower or higher than the estimated values. Previously, ISD(S)1 was used to provide all the Outpatients information; however, this information is now sourced from SMR00 excluding return attendances which uses ISD(S)1. Please note that SMR00 figures contained within each publication may also be subject to change in future publications as submissions may be updated to reflect a more accurate and complete set of data submissions. For details on all ongoing data issues please refer to the data issues and completeness document.

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Section B: Accident and Emergency Further Accident and Emergency (A&E) information and publications can be found on the Emergency Department Activity pages on the ISD website. For more information, contact [email protected]. In 2019/20 there were close to 1.7 million attendances at around 90 locations providing A&E services across Scotland. As well as 30 Emergency Departments, there are also minor injuries units, community hospitals and health centres that carry out A&E related activity which are typically GP or nurse led. Attendances to A&E were generally higher in summer months and lower in winter months. There was a large decrease at the time of the national lockdown due to COVID-19 in March 2020. September saw the highest average daily number of attendances (5,030), and March saw the lowest (3,265). One factor for the increase in attendances during summer could be better weather encouraging outdoor pursuits and resulting in an increase in the number of injuries presenting at Emergency Departments. Around one fifth of A&E attendances in 2019/20 resulted in an admission to the same hospital with the average daily number of admissions remaining relatively stable throughout the year at around 1,113.

Chart 3: Average daily attendances at and admissions from A&E, 2019/20

More than two thirds (70%) of A&E attendances resulted in discharge to a place of residence.

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Chart 4: Discharge destination from A&E, 2019/20

The number of attendances to A&E has seen a slow increase new daily attendances per day per year over the eleven-year period from 4,303 average daily cases in 2008/09 to 4,634 in 2019/20. There is a clear and consistent seasonal pattern with peaks in late spring/summer and troughs in winter. September 2019 saw the highest number of average daily attendances (5,030). However, due to response to COVID-19 March 2020 saw the lowest (3,265) average daily attendance in 2019/20 where you would normally expect attendances to start to pick up with spring.

Chart 5: Average daily attendances to A&E, 2008/09 – 2019/20

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Section C: Acute hospital admissions

Although much hospital-based care is carried out on an outpatient basis, a significant number of people have to be admitted to hospital for diagnosis or treatment. This can be part of a planned pathway of care, such as the requirement for an operation following a consultation at an outpatient clinic or a requirement for further diagnosis. Alternatively, the admission could be as a result of an emergency, for example, due to an accident or perhaps an acute exacerbation of a condition. When admitted to hospital, the patient is either treated on a same day basis, often referred to as a daycase, or as an inpatient, when the patient will normally spend at least one night in hospital. Some inpatients may be discharged from hospital on the same day as their admission. Around one in eight (691,000) of the Scottish population had at least one admission into hospital in 2019/20. The likelihood of being admitted to hospital is, as expected, highly correlated with age, reflecting the health status of the population. In 2019/20, around one person in three (33%) of the Scottish population aged over 75 was admitted at least once to hospital. By way of contrast, around one in twelve (8%) people aged 25-44 were admitted. The chart below shows, by age grouping, the percentage of the population who were admitted to hospital in 2019/20.

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Chart 6: Percentage of the population admitted to hospital in 2019/20 by age group

Source: SMR01 data.

Effect of population change in the future The population aged 65 and over is expected to increase by 20% from 2020 to 20302. Based on the above use of hospital healthcare services, this demographic shift in the population will have significant implications for the future demand on hospital services. This is a highly complex area. For further information please see here.

People living outwith Scotland There was a small proportion of hospital admissions that were for people who were resident from outwith Scotland. In 2019/20, there were approximately 8,200 such admissions, equating to 0.7% of all admissions.

2 Based on National Records of Scotland projections - https://www.nrscotland.gov.uk/statistics-and- data/statistics/statistics-by-theme/population/population-projections/population-projections-scotland/2018-based/

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Multiple admissions to hospital Most people (69%) admitted to hospital had only one admission per year. However, nearly one third (31%) of people who were admitted to hospital had two or more admissions. In 2019/20, • 69% (474,000) of those people admitted to hospital had one admission

• 18% (124,000) had two hospital admissions

• 13% (92,000) were admitted three or more times within the year.

Of the 406,000 people who had at least one emergency admission, 300,000 (74%) had one emergency admission into hospital, around 66,000 (16%) had two emergency admissions and around 40,000 (10%) had three or more.

Episodes of Care and Continuous Inpatient Stays Sometimes when a patient has been admitted to hospital, their care will be transferred between consultants as part of their pathway of care. For example, it is not uncommon for patients who are being treated in the specialty of geriatric medicine to have initially been under the care of a general physician as part of their hospital stay. Similarly; orthopaedic patients can sometimes be transferred to geriatric medicine as part of their ongoing treatment. These separate elements are known as ‘episodes’ of care within each continuous inpatient stay. For the purpose of these analyses, and in the context of this publication, hospital admissions are defined as the number of continuous inpatient stays in hospital where the patient was admitted. See the Glossary section for further information.

The majority of hospital admissions consist of one discrete episode of care. In total, there were 1,661,429 episodes associated with the 1,203,210 admissions to hospital in 2019/20.

Overall, there were 1,203,210 admissions to hospital in 2019/20; a 1% decrease compared to last year (2018/19) and a 2% decrease compared to five years ago (2014/15). Of these, • 466,984 (39%) were daycases • 137,481 (11%) were elective inpatient admissions • 594,033 (49%) were emergency inpatient admissions.

Detailed information on inpatient and daycase activity and multiple emergency admissions can be found in Table 2 - Inpatient and Daycase Activity and Table 3 - Multiple Emergency Admissions.

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How long do people stay in hospital?

How long a patient stays in hospital will be strongly related to the complexity of any operation carried out as well the underlying health condition of the person. The average length of stay has been reducing over the years. In 2019/20, the average length of stay was 6.1 days compared to 6.9 days in 2010/11. Patients admitted as emergencies generally stay longer than elective hospital admissions. In 2019/20: • Elective admissions: the average length of stay was 3.4 days • Emergency admissions: the average length of stay was 6.7 days.

The charts below show the length of stay profile for patients admitted to hospital. The first chart shows the distribution for all admissions; the subsequent chart highlights the different length of stay profiles experienced by elective and emergency admissions.

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Chart 7: Length of Stay profile for all inpatients (all admissions) in 2019/20

Source: SMR01 data.

• 22% of inpatient admissions were admitted and discharged on the same day.

• The most common stay in hospital involves one overnight stay, which was experienced by 24% of all inpatient admissions.

• Overall 46% of all inpatient admissions stayed one night or less in hospital.

• 4% of admissions remained in hospital for more than four weeks.

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Chart 8: Length of stay profile for Inpatients (Elective vs. Emergency) in 2019/20

Source: SMR01 data.

The length of stay profile for elective admissions differed from those admitted as emergencies. Patients admitted as an inpatient following a planned referral tend to be in hospital for shorter periods with 53% (73,537) staying no more than one night compared to 9% (12,622) staying for a week or more. By contrast, for patients admitted as an emergency those staying no more than one night was 45% (266,141) and those staying for a week or more was 20% (120,352); this often reflects the underlying health condition and multiple morbidities of these patients. Detailed information on length of stay can be found in Table 2 - Inpatient and Daycase Activity.

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Beds

The number of hospital beds has been reducing for many years. This is a result of both medical advances which have led to shorter stays in hospital for patients including planned daycase procedures (see Chart 10) alongside a shift to treatment and care in a more ambulatory setting or in the community. The average number of available staffed beds for acute specialties in Scotland in 2019/20 was 13,156. This compares with 13,091 (0.5% increase) last year (2018/19) and a 6% decrease (14,054) when compared to five years ago (2014/15). Of the 13,156 beds, 70% (9,260) were for medical specialties and 30% (3,896) were for surgical specialties. The percentage occupancy is the percentage of average available staffed beds that were occupied by inpatients during the period. The percentage occupancy has remained relatively stable over the years. In 2019/20, the percentage occupancy for acute specialties was 86.7%.

Detailed information on Bed numbers can be found in Table 4 - Beds.

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Reasons for admission There are many reasons why a person might have to be admitted to hospital. It could, for example, be due to an underlying health condition which requires treatment, monitoring or further diagnosis; it could be as a result of a sudden deterioration in health status; or it could be following a trauma incident. The five most common diagnosis groupings, accounting for 58% of all admissions are shown in the table below.

Table 2: Five diagnosis groupings accounting for the greatest number of hospital stays, Scotland, 2019/20

Diagnosis grouping Specific conditions No. of admissions Percentage

For example: -

Neoplasms Non-Hodgkin lymphoma, benign 192,158 16.0% tumour, breast cancer

Diseases of the For example: - 159,753 13.3% digestive system Appendicitis, pancreatitis

Symptoms, signs and ill- For example: - defined conditions, not Pain in throat and chest, abdominal 144,811 12.0% elsewhere classified and pelvic pain

Injury, poisoning and For example: - certain other Fracture of forearm, burns and 102,083 8.5% consequences of corrosions, poisonings and toxic external causes effects of substances.

For example: -

Diseases of the Pneumonia, asthma, chronic 101,489 8.4% respiratory system obstructive pulmonary disease (COPD) Source: SMR01 data.

The medical diagnosis of patients who were admitted to hospital differs markedly as to whether the admission was on a planned elective basis or as an emergency. For elective admissions, four out of ten admissions were either for neoplasms (cancer-related / suspicion of cancer) or were linked to the digestive system. For emergency admissions more than one-

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third were for general ‘signs or symptoms’ or Injury, poisoning and certain other consequences of external causes.

Table 3: Five diagnosis groupings accounting for the greatest number of hospital stays, Elective and Emergency Admissions, Scotland, 2019/20

Elective Admissions Emergency Admissions No. of % of No. of % of Diagnosis Grouping Diagnosis Grouping admissions total admissions total

Symptoms, signs and ill- Neoplasms 168,607 27.9 defined conditions, not 112,230 18.9 elsewhere classified

Injury, poisoning and certain Diseases of the 99,019 16.4 other consequences of 91,128 15.3 digestive system external causes

Factors influencing health status and Diseases of the respiratory 51,981 8.6 88,163 14.8 contact with health system services

Other symptoms, signs and Diseases of the eye 51,635 8.5 abnormal clinical and 70,968 11.9 and adnexa laboratory findings

Diseases of the Diseases of the digestive musculoskeletal system 48,905 8.1 60,417 10.2 system and connective tissue

Source: SMR01 data. NB. The elective admission figures include daycases.

See Table 5 - Diagnosis by NHS Board of residence for further detailed data on the above. Information on Diagnosis is also available by council area in Table 6.

High Resource Individuals Evidence from healthcare cost analysis in Scotland shows that in 2018/19, a small percentage of patients (5%) consume a considerable amount of hospital and GP prescribing expenditure/resources (69%). These patients are referred to as High Resource Individuals (HRI). As part of efforts to have evidence based healthcare delivery, the “High Health Gain” (HHG) risk prediction tool has been developed to calculate the risk of a person becoming, or continuing to be, an HRI in the next 12 months. For more information on the High Health Gain tool please visit the Health & Social Care integration area of the website.

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What procedures are carried out? In 2019/20 there were a total of 1,400,915 procedures performed within the acute hospital care setting. Of these, 83% (1,157,336) were carried out as a main procedure; a 4% decrease on last year (2018/19), with a 7% decrease in the last four years (2015/16). Three quarters (75%) of main procedures were carried out as an outpatient or daycase: • 425,337 (37%) of all procedures were carried out in an outpatient setting • 441,274 (38%) were carried out in a daycase setting • 290,725 (25%) were associated with at least one overnight stay in hospital or inpatients discharged the same day.

Some of the most common procedures carried out are within the Diagnostic imaging, testing and rehabilitation category. The table below shows the top five procedures (excluding the Diagnostic imaging category and other miscellaneous procedures) undertaken in 2019/20.

Table 4: Five procedures accounting for the greatest number of hospital stays, Scotland, 2019/20

Procedure No. of admissions Percentage

Chemotherapy for Neoplasms 83,993 7.3%

Upper gastrointestinal endoscopy 76,138 6.6%

Lower gastrointestinal endoscopy 73,287 6.3%

Cataract Procedures 45,865 4.0%

Other procedures on female genital 45,214 3.9% tract

Source: SMR00 and SMR01. Procedures information is provided in Table 7 – Procedures.

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Where are patients treated? The majority of patients are treated in a hospital located in their own local NHS Board area. However, around 1 in 11 (9%) admissions are to hospitals within other NHS Board areas. The reasons for patients not being treated in their own NHS Board area will include the provision of specialist national and regional services, where an emergency may have occurred or it may simply reflect the natural ‘catchment’ area of a particular hospital, being the closest to the patient. The flow of patients between NHS Boards varies depending on whether the admission is an emergency or not. Overall about one in five elective inpatient admissions (19%) were referred for treatment within another NHS Board area. A much smaller percentage of emergency admissions (6%) were to hospitals outwith the patients’ own NHS Board area. Some of these patients may have been subsequently transferred to another hospital. All NHS Boards refer some patients to the National Waiting Times Centre (NWTC). The Golden Jubilee National Hospital (GJNH) in Clydebank provides a range of national and regional services as well as being a national resource providing additional capacity to help meet the demand for planned (elective) procedures from across Scotland. The GJNH treated 5% of all elective hospital admissions in 2019/20.

Table 5: Flow of patients admitted to hospital between NHS Boards, Scotland, 2019/20

Admission Type Treated in own Board area Treated in another Board area

New Outpatients 93% 7%

All Admissions 91% 9%

- Daycase Admissions 89% 11%

- Inpatients (Elective) 81% 19%

- Inpatients (Emergency) 94% 6%

Source: SMR00 and SMR01.

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The number of patients being treated in another NHS Board varies depending on which NHS Board the patient resides in. As would be expected, there is less ‘flow out’ of patients from the four teaching Boards that provide most of the specialist or regional services NHS Greater Glasgow Clyde, NHS Lothian, NHS Grampian, NHS Tayside, compared with other NHS Boards. Around 4%-7% of patients from these four NHS Boards were treated elsewhere, which contrasts with 8% - 34% for other NHS Boards. Information on Cross Boundary Flow is available in Table 8 - Cross Boundary Flow.

Note – There are known issues with the quality of data presented such as the inpatient and daycase completeness. NHSScotland inpatient and daycase data are estimated to be 96% complete for the financial year 2019/20p. However, NHS Forth Valley data are estimated to be 41% complete for 2019/20p. For more information please see the data issues and completeness document which accompanies this publication

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Section D: Psychiatric Hospital Activity Psychiatric activity is analysed in more detail and explored together with mental health presentations in acute hospitals within the Mental Health Inpatient Activity publication which is updated on an annual basis. The next release of this publication will be in November 2020. For further information on mental health inpatient activity please contact [email protected]. The analysis below presents information on episodes of inpatient or daycase care where a mental health diagnosis was recorded in psychiatric and/or acute hospitals or units in Scotland up to 31 March 2019. It also includes records from certain care homes contracted by NHS Boards to provide this care which allows for more comprehensive analysis of inpatient mental health pathways in Scotland. However, please note that activity from the Learning Disability specialty has been excluded, as this information will be published in a separate publication. Figure 1 illustrates the rate of discharges per 100,000 population in acute and psychiatric facilities for Scottish Council areas in 2018/19. Note that this measure does not take account of age and sex differences which may influence differences between areas.

Figure 1: Rate of Mental Health Discharges1 (per 100, 000 population) from any treatment specialty in 2018/19 by council area of residence2

Source: SMR01 Acute Hospital Activity, SMR04 Psychiatric Hospital Activity 1. Excludes discharges from the Learning Disability specialty. 2. Council area refers to the local authority area in which the patient lives.

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Inverclyde had the highest rate of discharges for Mental Health in any specialty with a rate of 1,382 per 100,000 population and Aberdeenshire had the lowest rate at 402 per 100,000 population. When looking at non-psychiatric specialties only, however, West Dunbartonshire had the highest rate of discharges at 841 per 100,000 population and Aberdeenshire again had the lowest value of 172 per 100,000 population. Chart 9 shows the number of discharges for mental health in Psychiatric specialties, Non- Psychiatric specialties and any specialty for Scotland from 1997/98 to 2018/19. There were 48,780 discharges from any specialty for Mental Health in 2018/2019, the highest number of discharges for Mental Health since 1997/1998. Generally, the number of discharges for Mental Health from psychiatric specialties has decreased over the last 21 years while discharges from Non-Psychiatric specialties have been increasing. In 2016/2017, the number of discharges for Mental Health was higher in Non-Psychiatric specialties than for Psychiatric specialties for the first time. This trend has continued into 2018/2019.

Chart 9: Number of Mental Health Discharges1 in Psychiatric, Non-psychiatric and any specialty for Scotland2, 1997/1998 – 2018/2019

Source: SMR01 Acute Hospital Activity, SMR04 Psychiatric Hospital Activity 1. Excludes discharges from the Learning Disability specialty. 2. The data include people from outwith Scotland who have been treated in Scottish hospitals, including those treated in the State hospital.

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Section E: Now and then – a brief look over the past two decades The way NHS care has been delivered over the past two decades has changed significantly. This is often driven by advances in medical techniques and medication allowing patients either to stay significantly less in hospital once they have been admitted or indeed avoiding the need to be admitted at all. For example, the increased use of keyhole surgery has had a significant impact on patients’ treatment and rehabilitation. This section describes some of the changes that have taken place in the past twenty years. An increasing amount of healthcare is now being delivered either as an outpatient or daycase, rather than in an inpatient ward. The chart below shows the number of admissions to hospital over the past twenty years categorised as whether they were treated as an inpatient or daycase. Since 2000/01 the number of elective admissions into inpatient wards has fallen by around 85,000 (-38%); whilst at the same time the number of patients treated as daycases has increased by around 78,000 (+20%). In 2019/20, around 425,000 procedures were carried out in an outpatient clinic. Data on the number of procedures carried out in outpatient clinics was not comprehensively recorded in the earlier years but it is known that there has been a shift to patients being treated in an ambulatory care setting wherever possible. The number of emergency admissions has grown gradually over the 20-year period with, in 2019/20 around 126,000 more emergency admissions compared with 2000/01 (+27%). This increase is likely associated with the ageing population; for example there has been a 31%3 increase in the number of people aged 65+ over the same period. This changing profile of treatment presented below shows a reduction in planned elective inpatient admissions and the increase in the level of treatment delivered as a daycase.

Chart 10: Hospital Admissions, Scotland, 1999/00 - 2019/20

Source: SMR01 data.

3 Based on National Records of Scotland mid-year estimates time series data - https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/population/population- estimates/mid-year-population-estimates/population-estimates-time-series-data

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Table 6: Changes over time in NHS Care Delivery

Change Illustration

Greater use of Dermatology is now predominantly an outpatient based service. outpatient services - In 1999/00, there were around 12,000 admissions to hospital for dermatology and this has fallen to 840 in 2019/00. At the same time, the number of new patients seen in outpatients has increased from 80,000 to 126,000.

More patients In Ophthalmology, the majority of patients admitted to hospital for eye- being treated on a related conditions are now treated on a same day basis. daycase basis - In 1999/00, 36% of admissions were to an inpatient ward, whereas in 2019/20, it is 8% of admissions.

Increased use of Cholecystectomy (removal of gallbladder): keyhole surgery - More than nine out of ten patients now have this operation carried out using keyhole surgery. Almost 7,400 of these procedures were carried out in 2019/20. - This allows patients to be sent home much more quickly. A patient who undergoes this keyhole surgery stays in hospital around 5 days less than someone who has more invasive surgery. - Since 1999/00, the average length of stay for patients undergoing a cholecystectomy has reduced from 5.3 days to 2.5 days.

Shorter lengths of The average time patients stay in hospital for total hip or knee stay replacements has decreased by two thirds since 1999/00. - Hip replacements: The average length of stay has fallen from 14.5 days to 5.3 days. - Knee replacements: The average length of stay has fallen from 13.2 days to 4.3 days.

Source: Outpatient data are based on SMR00 data, Inpatient data come from SMR01 data.

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Glossary Acute Hospital Care/Activity 'Acute' hospital care includes activity occurring in major teaching hospitals, district general hospitals and community hospitals. Includes services such as consultation with specialist clinicians; emergency treatment; routine, complex and life-saving surgery; specialist diagnostic procedures; close observation; and short- term care of patients. Excludes obstetric services; psychiatric services; long stay care services; and non-consultant led clinics.

Available staffed beds This reflects the number of beds that can be used for inpatient or daycase care, multiplied by the number of days in a time period i.e. number of available staffed bed days over the year: Total number of available staffed beds (aasb) over the year = Allocated Beds + Borrowed Beds – Lent Beds + Temporary Beds

Average available staffed beds This is the average daily number of beds, which are staffed and available for the reception of patients (borrowed and temporary beds are included): Average number of available staffed beds per day (asb) = aasb / number of days in the year

Average length of spell This is the average (mean) number of days that a patient spends in hospital during a specialty spell at a given location. It is calculated by dividing the total length of spell for all inpatients, at a given location, during a year by the total number of specialty spells.

Average length of stay This is the average (mean) number of days that a patient spends in hospital during a CIS. It is calculated by dividing the total length of stay for all inpatients during a year by the total number of CISs.

Continuous Inpatient Stay (CIS) A continuous inpatient stay is a period of time that a patient spends as an inpatient. However, a patient may change consultant, significant facility, specialty, and/or hospital during a continuous inpatient stay. A single CIS may contain several specialty spells.

Probability matching methods have been used to link together individual SMR01 hospitals episodes for each patient, thereby creating "linked" patient histories. Within these patient histories,

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SMR01 episodes are grouped according to whether they form part of a continuous spell of treatment from first episode admission to last episode discharge (whether or not this involves transfer between hospitals or even NHS Boards).

When showing information by CIS, the admission type e.g. elective/emergency is determined by the first admitting episode. As a result, transfers will generally not appear within the CIS analysis. When a transfer does appear it is often the result of a patient being transferred from another provider unit e.g. outwith Scotland. However, there will also be instances where the admission type has been incorrectly coded. Unfortunately, it is not possible to fully ascertain what the correct admission type should have been. As a result, a small proportion of transfers do appear within the various tables.

For the purpose of these analyses, hospital admissions are defined as the number of continuous inpatient stays in hospital where the patient was admitted.

Cross-boundary flow Cross-boundary flow refers to the relationship between the NHS Board in which patients live and the NHS Board where they are treated.

Daycase A daycase is when a patient makes a planned attendance for a day to a specialty for clinical care and requires the use of a bed, or trolley in lieu of a bed. Whilst a daycase is usually completed within the same day, the patient may need to be admitted as an inpatient if they are not fit to be discharged.

Did Not Attends (DNA’s) There are people who do not attend their outpatient appointment without making the hospital aware in advance; these appointments are known as Did Not Attends (DNA's).

Discharge A hospital discharge marks the end of an episode of care. Discharges include deaths, transfers to other specialties/significant facilities and hospitals, and discharges home or to other regular place of residence.

Elective / Planned Admission An elective, or planned, admission is when a patient has been given a date to come to hospital for a planned procedure or treatment.

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Emergency Admission An emergency admission occurs when, for clinical reasons, a patient is admitted unexpectedly at the earliest possible time. This might be after a visit to a doctor, emergency department or calling an ambulance.

Episode An SMR01 episode is generated when a patient is discharged from hospital but also when a patient is transferred between hospitals, significant facilities, specialties or to the care of a different consultant.

Inpatient A patient is termed an inpatient when they occupy a staffed bed in a hospital and either remains overnight (whether intended or not), or is expected to remain overnight but is discharged earlier. An inpatient’s admission can be an emergency, an elective or as a transfer.

Length of spell This is the total number of days that a patient spends in hospital during a specialty spell at a given location.

Length of stay This is the total number of days that a patient spends in hospital during a CIS.

New outpatient attendances New attendances are the number of attendances at an outpatient service for a new case.

Non-NHS Provider Data Non-NHS Provider figures relate to patients treated in non-NHS locations such as private hospitals, hospices, nursing homes, care homes, etc. Patients who receive treatment at a Private (independent) hospital which is paid for by the NHS Board should be recorded within the Scottish Morbidity Record (SMR) by the relevant NHS Board. However, if a patient is treated privately (i.e. treatment paid for by patient or private insurer) and there is no NHS involvement then this activity will not be recorded within the SMR.

Occupied Bed An occupied bed is an available staffed bed, which is either being used to accommodate an inpatient or reserved for a patient on pass: Total number of occupied bed days (tobd) = Sum of the number of occupied beds for each day of the year.

Average number of occupied beds per day (aob) = tobd / number of days in the year.

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Outpatient An outpatient is a patient who attends a consultant or other medical clinic or has an arranged meeting with a consultant or a senior member of their team outwith a clinic session. Outpatient attendances involve treatment or assessment that only take a short time to complete. Outpatient attendances are categorised as new or return (follow-up).

Patients This relates to individual patients. However, the same patient can be counted more than once, if they change subgroup (e.g. specialty, type of admission, NHS Board etc.). In these cases, a patient will be counted once within each subtotal, but only once in the overall total.

For example, if a patient was admitted three times in a single year, twice as an emergency admission and once as an elective admission, they would be counted once in each sub-total of emergency and elective admissions, and once in the overall total of admission types.

The same patient will also be counted for each of the financial year they were admitted in hospital, for example if a patient was admitted in 2010/11 and 2012/13 they would be counted in each of these years.

Percentage Occupancy (%) The percentage occupancy is the percentage of average available staffed beds that were occupied by inpatients during the period: Percentage occupancy = (aob / asb) x 100

Return outpatient attendances Return (follow-up) attendances are the number of attendances to an outpatient service which are related to an original case.

Scottish Index of Multiple Deprivation (SIMD) The SIMD uses a wide range of information for small areas (data zones) to identify concentrations of multiple deprivation across Scotland. Further information can be found at https://www.gov.scot/collections/scottish-index-of-multiple- deprivation-2020/.

Specialty A specialty is defined as a division of medicine or dentistry covering a specific area of clinical activity. There are two specialty groupings that most specialties sit in: medical and surgical. A full listing of specialties covered by the data sets

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used in this publication is available on the NHSScotland Health & Social Care data dictionary web page.

Specialty spell A specialty spell is a period of time that a patient spends as an inpatient in a specialty at a given location. However, a patient may change consultant, significant facility, and/or hospital during a specialty spell.

For more information on the specialty spells methodology please see the Specialty Spells Methodology paper accompanying this report.

Transfer A transfer occurs when a patient needs to be moved to another doctor, clinical specialty, or facility within the hospital or another hospital altogether to receive the specialist care they require after they have been admitted to hospital. The majority of these transfers are planned (elective) transfers. Note: When showing information by CIS, the admission type e.g. elective/emergency is determined by the first admitting episode. As a result, transfers will generally not appear within the CIS analysis. When a transfer does appear it is often the result of a patient being transferred from another provider unit e.g. outwith Scotland. However, there will also be instances where the admission type has been incorrectly coded. Unfortunately, it is not possible to fully ascertain what the correct admission type should have been. As a result, a small proportion of transfers do appear within the various tables.

Further details are available in the NHS Scotland Health & Social Care data dictionary

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Contact Kirsty Anderson, Principal Information Analyst Quality Indicators Secondary Care Team Phone: 0141 282 2243 Email: [email protected]

Chris Deans, Senior Information Analyst Quality Indicators Secondary Care Team Phone: 0131 314 1749 Email: [email protected]

Róisín Farrell, Senior Information Analyst Quality Indicators Secondary Care Team Phone: 0131 314 1029 Email: [email protected]

Evelyn Shiel, Senior Information Analyst Quality Indicators Secondary Care Team Phone: 0131 314 1054 Email: [email protected]

Quality Indicators Secondary Care Team Email: [email protected]

For all media enquiries please email [email protected] or call 07500 854 574.

Further Information Disclosure control methods have been applied to the data in order to protect patient confidentiality, therefore some figures on total counts may not be additive. Further information and data for this publication are available on the Annual Acute Hospital Activity and NHS Beds data web page. The next release of this publication will be in August 2021.

Open data Data from this publication is available to download from the Scottish Health and Social Care Open Data Portal.

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Rate this publication Let us know what you think about this publication via. the link at the bottom of this publication page on the PHS website.

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Appendices Appendix 1 – Background information Data sources

Outpatient, inpatient and daycase activity data are collected across NHSScotland and are based on nationally available information routinely drawn from hospital administrative systems across the country. The principal data sources are - SMR00 (patient-level outpatient records) - source for outpatients (except return attendances - SMR01(inpatients and daycases discharges from non-obstetric and non-psychiatric specialties) - source for acute inpatients and daycases, and - ISD(S)1 (aggregate hospital activity) - source for bed data returns and return outpatients ISD(S)1 is a set of aggregated summary statistics on activity in hospitals in NHSScotland and is derived from monthly and quarterly returns from the NHS Boards. ISD(S)1 is the only source of bed occupancy and bed availability data and contains summarised data by NHS Board of Treatment, hospital and specialty. ISD(S)1 is also used for return outpatient activity since completeness for return outpatients in SMR00 is poor.

Revisions

All tables will be revised annually. In general, these revisions have minimal effect on the statistics. If missing/incomplete data is significant and is due to be submitted and published in subsequent releases this will be highlighted within the notes on the affected table. Please see the PHS revisions policy for further details. NHS Boards can update both their current and historical data monthly. This may result in changes in the recent data shown from one publication to another. The data for 2019/20 is provisional. Provisional data is subject to change in future publications as submissions may be updated to reflect a more accurate and complete set of data submissions.

Please see Appendix 3 for further information on revisions relevant to this publication.

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Appendix 2 – Data Quality and Completeness Data Quality

Scottish NHS Boards have a responsibility to ensure their SMR data are accurate, consistent and comparable across time and between sources. The PHS Data Quality Assurance team (DQA) audit SMR data at NHS Boards to determine if it has been properly recorded in accordance with national rules and standards. The DQA team’s assessment web page contains reports from past audits of inpatient/daycase data, including findings on the accuracy of submitted SMR01 data items used in our analysis (specialty, admission type, etc.). Currently it is difficult to describe and quantify accurately the level of operations and clinical procedures carried out in an outpatient setting. This is particularly relevant for monitoring how changes in clinical practice have enabled the transfer of certain clinical activities, previously requiring inpatient or daycase admission, to outpatient clinics. Whilst outpatient procedure recording has improved in recent years, gaps in the completeness and coverage remain. It should be noted that that there are apparent differences between activity figures published within the Hospital Care, Waiting Times and Finance web pages: • The figures for elective admissions and new outpatients in the Acute Hospital Activity publication are considerably higher than the equivalent information published on the Waiting times web pages for inpatients, daycases and outpatients. This is largely due to the use of different definitions for the two sets of figures. • The figures for inpatient and daycase activity in the Acute Hospital Activity publication differ slightly when compared to the equivalent information released in the Finance web pages. This is largely due to the use of different definitions for the two sets of figures. The Finance publication also excludes consultant-only transfers from the inpatient figures. For detailed information on the data sources and clinical coding used within Hospital Care analysis please refer to the SMR Datasets, ISD(S)1 data collection and Terminology Services web pages.

SMR completeness

Information on SMR data completeness can be found on the Hospital Records Data Monitoring SMR Completeness web page, while information on the timeliness of SMR data submissions can be found on the SMR Timeliness web page. Details on SMR completeness (at the time the data extract was taken) can also be found as an associated excel data file accompanying this publication. PHS are working with NHS Boards to resolve ongoing data submission issues. The majority of these issues have resulted from implementation of the PMS TrakCare system and other existing system issues. Further details of these issues can be found within the data issues and completeness document which accompanies this publication.

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Estimations / provisional data

It should be noted that outpatient, inpatient, daycase and beds figures may include an element of estimation for any incomplete or outstanding data submissions. Where possible, missing or incomplete ISD(S)1 data have been estimated for affected NHS Boards by averaging the last three complete monthly submissions from the relevant NHS Board unless otherwise stated. Therefore, data for the latest time period should be treated as provisional as subsequent data submissions could be lower or higher than the estimated values. Specific issues are as follows:

Outpatient

It should be noted that previous figures provided may have included an element of estimation for any incomplete or outstanding data submissions. Therefore, subsequent data submissions could be lower or higher than the estimated values. Previously, ISD(S)1 was used to provide the Outpatients information; however, this information is now sourced from SMR00 (except return outpatients). This is due to data quality concerns around return outpatients in SMR00 for these time periods. Please note that SMR00 figures contained within each publication may also be subject to change in future publications as submissions may be updated to reflect a more accurate and complete set of data submissions.

Beds Methodology

NHS Grampian and NHS Highland • NHS Grampian was unable to submit beds information from quarters ending March 2011 until June 2014, to Public Health Scotland due to system implementation problems. NHS Highland was unable to submit beds information from quarters ending March 2014 until September 2015. • We used a straight line extrapolation between the last and first known data points. • We appreciate that the actual change in bed numbers may have been more of a step change in service delivery at different points throughout the time period, but feel straight line estimation is the most pragmatic and proportionate solution to filling the gaps.

For details on all ongoing data issues please refer to the data issues and completeness document.

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Appendix 3 – Publication Metadata

Metadata Indicator Description Publication title Acute Hospital Activity and NHS Beds Information in Scotland, September 2020 Description Summary of inpatient, daycase and outpatient activity, including details about specialties, diagnoses, procedures; admission type, length of stay, and bed statistics for NHSScotland Theme Health and Social Care Topic Hospital Care Format Excel, Word, PDF Data source(s) ISD(S)1 aggregated data returns (beds and return outpatients), Scottish Morbidity Records SMR01 (inpatient/daycase), SMR00 (outpatient – excluding returns) Date that data are acquired July 2020 Release date 29 September 2020 Frequency Annual Timeframe of data and Detailed Annual Acute Hospital Activity Information up to March 2020 timeliness Continuity of data Reports include a mix of 5,10, and 20-year trend annual data up to 2019/20. There has been a re-structuring of tables previously presented to streamline the process, and provide users with more concise tables with additional functionality and information available.

As part of this streamlining process, the “Number of hospital stays, bed days and rates for selected long term conditions” table is no longer provided. Both the diagnosis by NHS board of residence and diagnosis by council area contain all of the data this table used to hold and some diagnoses are provided in more detail. The only slight difference is in how osteoarthritis (ICD10 codes M15-M19) is now shown. In this publication the codes are separated across coxarthrosis [arthrosis of hip] (M16), gonarthrosis [arthrosis of knee] (M17) and other types of osteoarthritis [arthrosis] (M15, M18-M19). As a result, there may be slight differences in numbers due to multiple diagnoses occurring in one stay.

In both of the Diagnosis tables the “All diagnoses” total now contains all diagnoses. Previously, “Chapter XX External Causes of Morbidity and Mortality” of the ICD10 classification system were excluded from the total.

In the Procedures table, ‘Other procedures on kidney’ and ‘Other urinary tract endoscopy’ have been altered slightly to include endoscopic procedures together and keep non-endoscopic procedures under ‘Other procedures on kidney’. Counts for ‘Procedures (excluding imaging, injections, infusions, x- ray)’ are no longer included in this table due to coding inconsistencies. Please see Table 7. Procedures for all OPCS codes used.

Daycases have been included in the average length of stay and average length of episode calculations. This decision was taken to make the methodology more consistent with the quarterly publication.

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There are known issues with the quality of data presented such as inpatient and daycase completeness. For more information please see the data issues and completeness document which accompanies this publication.

Due to problems with the implementation of a new patient administration system, no ISD(S)1 returns were submitted for NHS Grampian from quarters ending March 2011 until June 2014. NHS Highland has had similar problems from quarters ending March 2014 until September 2015. Missing data were estimated and more details on this can be found in the Beds Methodology section in Appendix 2.

A review of specialty spells (formally stays by specialty) has been undertaken prior to the September 2020 publication. As a result, there may be some differences when comparing with previous publications. For further information, please refer to the Specialty Spells document which accompanies this publication.

Acute Assessment Unit (AAU) / Ambulatory Emergency Care (AEC) activity

Definitions

• Acute Assessment Unit (AAU) The AAU is a dedicated facility for the acute clinical care of patients that present to hospital as clinical emergencies or who develop an acute clinical problem while in hospital. The units may also carry out some planned healthcare.

Generally, these units have both trolleyed areas and staffed beds which form part of the hospitals bed complement. Where trolleys are used in lieu of beds, patients should be counted as inpatients.

Acute Assessment Unit (AAU) is the preferred term for services also known as: o medical/surgical assessment unit o combined assessment units o clinical assessment units o acute medical (assessment) units o paediatric assessment units o acute receiving ward/unit admission unit

These cases should be recorded under significant facility 40.

• Ambulatory Emergency Care (AEC) An Ambulatory Emergency Care Unit is a multidisciplinary ‘one stop’ service.

It provides Outpatient and Daycase services only.

These cases should be recorded under significant facility 39.

National recording of AAU & AEC activity

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Currently AAU activity is only being submitted by some NHS Boards within SMR01. NHS Greater Glasgow & Clyde AAU activity stopped in 2017. NHS Highland have been submitting AEC cases via SMR01 using criteria agreed by PHS to ensure that they pass validation rules as an interim measure. NHS Greater Glasgow & Clyde has opted to record these cases differently from NHS Highland since they consider a number of these cases to be non- elective daycases which, due to recording rules, cannot be recorded that way on TrakCare. As such they took the decision to record them as Emergency Department activity to allow them to be able to follow the patient through the system. However, from September 2019 onwards, the Royal Alexandra Hospital within NHS Greater Glasgow & Clyde have started to record AAU cases again within SMR01. NHS Western Isles have started submitting AEC cases via SMR00 in 2020.There are ongoing discussions with NHS Boards, the Scottish Government and PHS on the most appropriate way for capturing this activity including AEC cases. AEC is under the scope of SMR00 Modernising Review, and it is hoped that national definitions and guidance on how to record this activity can be agreed by all NHS Boards.

The number of emergency admissions presented in the ‘Multiple Emergency Admissions' table may differ from that presented in the 'Inpatient and Daycase' table. This is due to slight differences in methodology. Data from previous years are also not comparable with this publication due to changes in methodology (e.g. exclusion of emergency daycases) from September 2020.

Change to Council Area/NHS Board codes: There has been two minor boundary changes to council area since early 2018. The first change was for Keltybridge and Fife Environmental Energy Park at Westfield. The official implementation date of this change was 2nd February 2018. As a result, the following geographies are impacted and new 9-digit codes have been generated: Council Areas, Electoral Wards, Health Boards, Health and Social Care Partnerships, Police Divisions, Fire and Rescue, Postcodes and LAU1. The changes for geography codes commonly used by PHS are as follows:

NHS Board: Old code New code NHS Fife S08000018 S08000029 NHS Tayside S08000027 S08000030

Council Area: Old code New code Fife S12000015 S12000047 Perth & Kinross S12000024 S12000048

The second change has been to the Cardowan and Stepps areas of Glasgow and Lanarkshire. The official implementation date of this change was 1st April 2019. As a result, the boundaries for Health Board (NHS Great Glasgow & Clyde, NHS Lanarkshire) and HSCP (Glasgow City, North Lanarkshire) have changed to align with the new council area boundary. The changes for geography codes commonly used by PHS are as follows:

NHS Board:

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Old code New code NHS Greater Glasgow & S08000021 S08000031 Clyde NHS Lanarkshire S08000023 S08000032

Council Area: Old code New code Glasgow City S12000046 S12000049 North Lanarkshire S12000044 S12000050

Health and Social Care Partnership (HSCP): Old code New code Glasgow City S37000015 S37000034 North Lanarkshire S37000021 S37000035

Hospital/location code changes: Dumfries &Galloway Royal Infirmary (Y104H) moved location in December 2017, and activity is now recorded under a new code, Y146H. The name remains “Dumfries & Galloway Royal Infirmary”. To ensure that no activity is missed, and to allow trends to be presented, the two hospital codes Y146H and Y104H (for SMR01 and SMR00 activity) are combined in our analyses under Y146H. The old site (Y104H) still exists and is now a treatment centre named “Mountainhall Treatment Centre”. This new activity will be reported separately under a new code (Y177C) which came into effect in December 2017. From 1st December 2018, Stirling Community Hospital closed along with all its wards and the Bellfield Centre opened. The Bellfield Centre provides short-term inpatient care, assessment or rehabilitation for people who require additional support following an operation or illness. Within the Bellfield Centre there is one new NHS ward, the Wallace Suite. Most of the beds are converting to partnership controlled intermediate beds. This may impact on NHS Forth Valley’s bed figures. Balfour Hospital (R101H) moved location between April and November 2019. Both the hospital name and code have changed to “The Balfour” and R103H respectively. For inpatient and beds activity, both hospital codes have been added together. For outpatient activity, both hospital locations are reported separately whilst this move is still in transition. “Prince and Princess of Wales Hospice” and “Prince & Princess of Wales Hospice” – new location has been built in 2018 with different location codes. The new location code is G604V; the old one G414V). Geographical coding changes have been applied to make the coding of ‘Other’ locations e.g. when patients have no fixed abode and are resident outside Scotland/UK to be consistent with PHS Open Data Geography Codes.

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new and emerging technologies, and maximise the role of clinicians across Primary, Secondary and community based services.

In order to meet the objectives set out in the “Modern Outpatient” agenda and to ensure our secondary care datasets meet future information needs, PHS has been working with key stakeholders to establish a Modernising Patient Pathways Programme (MPPP) of all SMR datasets, with an initial focus on outpatients, to take account of new, and future, service delivery models. This will support patient and service management at Board level as well as providing more accurate and appropriate clinical information at a national level. The SMR00 Modernisation work may have an effect on the number of SMR’s submitted. In addition, other disciplines of staff are increasingly carrying out care for patients which may impact on the number of consultant clinics run. Revisions statement All revisions to data within this release are planned and are due to incomplete data returns at the time of publication. All tables will be revised annually or quarterly. In general, these revisions have minimal effect on the statistics. If data providers discover that data submitted for publication is incorrect, and/or missing/incomplete and is significant, this can be re-submitted and published in subsequent releases. Any changes will be highlighted within the notes on the affected table. Please see the PHS revisions policy for further details. Revisions relevant to this The geography, SIMD and population files are based on the latest or most publication appropriate versions available at the time of data analysis. See the excel data tables for further information. Postcode has been used to map directly to NHS Board and Council Areas rather than using the existing NHS Board and Council Area variables within the SMR dataset. This may introduce minimal changes when compared to previous releases.

Procedure & Diagnosis recording Please see the excel data tables for information on changes in coding.

Office for Population Censuses and Surveys Classification of Surgical Operations and Procedures (OPCS)4. There have been changes to the OPCS4 coding used in this publication: OPCS 4.9 has been introduced and the relevant code changes have been included in this analysis. Some minor coding changes have occurred to better represent the procedure groups. ‘Peripheral Arteriography’ has been renamed ‘Other Arteriography’

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‘Peripheral angioplasty/stent’ has been renamed ‘Other angioplasty/stent’

International Statistical Classification of Diseases and Related Health Problems (ICD) version 10, 5th edition There have been changes to the ICD10 coding used in this publication: ‘Renal calculi’ has been renamed ‘Urolithiasis [urinary tract calculi]’ ‘Inflammatory Bowel Disease’ is now called ‘Crohn's disease and ulcerative colitis’ ‘Osteoarthritis’ has been renamed ‘Osteoarthritis [arthrosis]’

Also see continuity of data section. Concepts and definitions Please see the Glossary section within this report and the excel data tables which accompany this publication. Further details are also available on the Health and Social Care Data Dictionary. For detailed information on the data sources and clinical coding used within Hospital Care analysis please refer to the SMR Datasets, ISD(S)1 data collection and Terminology Services web pages. Relevance and key uses of To compare areas and activity across Scotland and view trends over time. the statistics To allow NHS Board employees to compare activity levels nationally, e.g. NHS clinical consultants interested in their specialty figures by NHS Board, NHS information managers planning capacity, to assist in the development of Service Agreements between NHS Boards. To investigate the implications of common systemic diseases in Scotland as a basis for assessing health demands in the future. To assess whether patients were treated within or outwith their own NHS Board. To allow members of the public to readily access information on the number of hospital admissions for specific diagnoses or procedures that may be of personal interest to them. To assist students and universities conducting medical studies for research purposes. Private companies interested in hospital activity levels in Scotland such as pharmaceutical companies, consultancy companies employed by NHS Trusts in England, advertising/media companies on behalf of clients. To provide statistical information for political campaigns, e.g. to halt reductions in acute NHS beds. Accuracy Please refer to Appendix A2 of this report. Completeness Please refer to Appendix A2 of this report. Comparability The Office of National Statistics United Kingdom Health Statistics 2010 publication provides a single point of reference for the comparison of key figures between the four constituent countries of the UK. Hospital activity and bed statistics can be found within chapters 6 and 8 respectively. Whilst the four UK countries worked collaboratively to maximise the comparability of the figures, it is important to note that differences between the countries remain in the way that data measures are collected and classified, and because of

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differences between countries in the organisation of health and social services. The report includes the details of these differences where relevant. Hospital activity data from England, Wales and Northern Ireland are available separately but should not be directly compared with published data from Scotland. • England - Hospital Episode Statistics (HES) • Wales - NHS Hospital Activity • Northern Ireland - Hospital Statistics & Research

Also see Appendix 2 Accessibility It is the policy of Public Health Scotland to make its web sites and products accessible according to published guidelines. Coherence and clarity Measures to enhance coherence & clarity within this report include: explanatory table/chart notes, minimal use of abbreviations/abbreviations explained in text and notes on background and methodology. Previous publications are available on the Hospital Care Landing page. Information published prior to September 2019 is listed on the Hospital Care Publication page. Value type and unit of In general, figures are shown as numbers, percentages or rates per 100,000 measurement population. Disclosure Disclosure control methods have been applied to the data in order to protect patient confidentiality, therefore some figures may not be additive. The PHS protocol on Statistical Disclosure Protocol is followed. Official Statistics The UK Statistics Authority has designated these statistics as National designation Statistics signifying compliance with the Code of Practice for Statistics, available on the UK Statistics Authority website. UK Statistics Authority The statistics last underwent a full assessment by the Office for Statistics Assessment Regulation (OSR) against the Code of Practice in September 2011. The OSR is the regulatory arm of the UK Statistics Authority. Last published 10 September 2019 Next published August 2021 Date of first publication Help email [email protected] Date form completed 11 September 2020

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Appendix 4 – Early access details

Pre-Release Access Under terms of the "Pre-Release Access to Official Statistics (Scotland) Order 2008", PHS is obliged to publish information on those receiving Pre-Release Access ("Pre-Release Access" refers to statistics in their final form prior to publication). The standard maximum Pre-Release Access is five working days. Shown below are details of those receiving standard Pre- Release Access.

Standard Pre-Release Access: Scottish Government Health Department NHS Board Chief Executives NHS Board Communication leads

Early Access for Management Information These statistics will also have been made available to those who needed access to ‘management information’, i.e. as part of the delivery of health and care:

Scottish Government Performance and Delivery Directorate – Deputy Director, Principal Information Analyst

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Appendix 5 – PHS and Official Statistics

About Public Health Scotland (PHS) PHS is a knowledge-based and intelligence driven organisation with a critical reliance on data and information to enable it to be an independent voice for the public’s health, leading collaboratively and effectively across the Scottish public health system, accountable at local and national levels, and providing leadership and focus for achieving better health and wellbeing outcomes for the population. Our statistics comply with the Code of Practice for Statistics in terms of trustworthiness, high quality and public value. This also means that we keep data secure at all stages, through collection, processing, analysis and output production, and adhere to the ‘five safes’.